Advice to Bad Therapists: Know your Responsibilities or Get the Hell Out

When I was in graduate school, students would sometimes watch therapy sessions from behind a one-way mirror. The patients were advised of this before they came into our clinic so as to avoid any surprises. The extremely low fees we offered were considered a trade-off of sorts in exchange for getting treatment from students who needed to be supervised. Sometimes the patients were initially quite skittish at the idea that there could be as many as five people staring through the glass, but the reality was that whoever was watching was focusing much, much more on what the student was saying than the patient. Once people recognized that fact, they often forgot about the mirror altogether.

One of my professors had a saying about a shrink’s job: you have to ask the hard questions and say the difficult things that others will not. This means covering topics that many avoid such as finances or sex. In fact, when I worked with sex offenders (a topic you can read about in “Crazy”), I was required to take a detailed history of their sexual life. This included masturbation practices, fantasies, number of partners, etc. One of my colleagues would invariably ask, on a scale of 1-10, how the offender rated himself on various sexual variables: cunnilingus, kissing, manual stimulation and even anal sex. To this day, I’m still not entirely sure why.

During an initial session at our university clinic, one of my classmates had a new patient who was seeking help for depression. A mid-30’s, Caucasian male, he had a type of deformity around his mouth. It wasn’t clear if it were perhaps Cleft Palete or perhaps just a temporary injury, as it was covered to a marginal degree with the man’s facial hair. The therapist-in-training, whom I’ll call Shelly, went through most of the interview asking standard questions: duration and severity of symptoms, family history, social history, drug and alcohol use, etc. After the information was obtained, it was standard practice to ask the patient to wait in the therapy room while the student spoke with the supervising professor before making any treatment recommendations. Shelly explained that they would be taking a short break and she left the room to meet with us in the darkened consultation area on the other side of the glass.

“Good job,” the professor said. “But what is up with his lip?”

“I’m not sure,” Shelly said. “Should I ask him about it?”

Immediately a divide was noted by the people in the room. Half of us saw it as causing unnecessary self-consciousness on the part of the patient. The others believed it could lead to “enlightening information.”

“What’s the point? You think by finding out his lip was banged up in a bar fight, you’re going to recommend a new kind of therapy, or maybe Prozac instead of Lexapro?” my always straightforward colleague, Dr. John asked.

“What if it was caused by an abusive parent?” a student countered. “We’d want to know that.”

“Maybe that type of information should be obtained over time, when he’s gotten comfortable,” I said. “He’s got six students and a professor staring at him, and Shelly isn’t even going to be his therapist.* Let him get settled in with whomever is going to be treating him and she can address it with him then.”

“No no,” the professor said. “Remember, we’ve got to ask the tough questions. That’s our job. Plus, this would be a great way to test his defense mechanisms, see how he handles interpersonal conflict and sensitive matters, how much ego strength he has.”

It all sounded like bullshit to both John and me. But sure enough, Shelly went back into the room, sat down, and began talking.

“So, Mr. _______, let me just clarify a few things. You’ve mentioned that you don’t drink any alcohol, have been feeling depressed for 6 weeks and have a good social support system. Is that correct?”

The man nodded, undoubtedly wondering why she was picking random, disconnected statements for which to seek clarification.

At that point she leaned over the table between the two of them. “I’ve also noticed you’ve got something on your lip,” she said, squinting her eyes to get a closer look at the disfigurement. She even went as far to touch her own lip, just in case the man couldn’t understand what body part she was talking about.

“Yes, yes” the man stammered. “I was born this way, it’s a birth defect.” The man then looked at the mirror sheepishly, blushed and briefly covered his mouth. So did Shelly.

After what seemed like minutes of awkward pause, Shelly wrapped up the meeting in standard format, telling him that his situation would be presented to the treatment team and that a therapist would contact him later that week to set up his first true treatment session. A few days later, a very unsurprised Dr. John made his thoughts known after it was discovered the man had decided to seek treatment elsewhere, somewhere “where he felt more comfortable.”

“Shelly, you’re a complete fuck up,” he concluded. “I hope someone disfigures your face and then asks you every day how it happened.”

It puzzled me why someone who would clearly know how Shelly’s face was disfigured would ask her about its origins on a daily basis, but I had to agree that it was a grave error to ask the patient about his physical abnormality.

Now one could argue against the notion that the man may have had very poor defense mechanisms and would have dropped out of treatment soon anyway. In fact, a significant number of clients come in for an initial session and do not return for myriad reasons (e.g., failed expectations, a decrease in symptoms simply due to the passage of time, financial issues). Hell, no one could say for sure that it was entirely due to Shelly’s question that drove the man away, or perhaps even her bizarre method of looking like a curious orangutan as she stared at his lip was the only problem here. But the fact remains that the client did not come back, which is bad on all levels: treatment, business and even basic, interpersonal etiquette. Shelly’s move, although dictated by the professor, was a significant error in judgment.

Whether you’ve been in the field for 30 years or just considering entering this field, you need to remember that with the power and freedom to discuss intimate details of a person’s life comes great responsibility. What is old hat to us is new and foreign to others. You can ask every patient, every day of your career how often he jerks off, but that won’t make that question any easier for the person who is sitting down with a shrink for the first time. Every question and statement you make must come with a level of sensitivity and forethought, a realization that while you may be completely comfortable in your own skin in your own office, the person in front of you likely won’t be. It’s your job to make them feel safe before you request they reveal their secrets to you. And if you can’t do that, if you have to rely on your title or experience or even prior success to justify methods of creating discomfort in the name of “needing to ask the tough questions,” you might want to consider another line of work. Because at the end of the day, you’re often doing more harm than good.

20 Responses to “Advice to Bad Therapists: Know your Responsibilities or Get the Hell Out”

Do you think there could have been a more sensitive way to pose the question to the patient that would have been more successful? I agree with your colleagues/classmates that the disfigurement could potentially have lead to valuable information, especially if it perhaps related to his depression and a negative self-image…but I agree with you and Dr. John on the “complete fuck up” of the student’s asking the question the way she did.

I guess I’m just wondering if there’s a way to reconcile these two sides, or if you think even asking the question in a less clumsy/more empathic way wouldn’t have been worthwhile?

I’m sure there is but, more importantly, new therapists need to realize that if something is truly important, it was invariably emerge over and over. Too many shrinks see or hear something that gets them wide-eyed and they simply have to go for it, often to satisfy their own curiosity. If the man’s face was important, why that is so would come out soon enough.

I’m wondering what the purpose of “asking the tough question” in what can only be deemed an intake appointment is. Since the individual would be meeting with a therapist after this, what does it matter what significance the birth defect had at this point? That’s something that should well have waited until actual therapy instead of the history-taking.

Also, I do have to question the oversensitivity of this person; who, if leaving due to a tactless observation, may likely abandon therapy along the way for any trivial reason.

I think the “you have to ask the tough question” thing is just the professor dealing with his own insecurities about the practice of psychology. Maybe he feels that sitting in a room and talking to someone isn’t a legitimate profession, so he has created a way of explaining to himself how what he does is more than that.

Same thing with lawyers, they’ll wax philosophical about “pursuing justice” or some shit, when most of their practice is just filing so many motions that opposing counsel would rather pressure their client into settling than to deal with the paperwork.

Not at all trying to demean your profession, what I’m saying is that it sounds like your professor doesn’t actually believe in its value.

As for the face thing, it’s entirely plausible that having a facial abnormality would affect your mental state. It will affect every single interaction you ever have, so there’s going to be some psychological effects. I’d say ask about it the same way you’d ask about anything else. If the patient had a twitch, or wrings his hands, how would you ask about that? The nicest way to approach it is with a neutral professional interest. If you tip toe around it, you’ll make the patient feel as if it’s something that needs to be tip toed around. “So, I’ve noticed your a freak. How does that make you feel?”

I can see why one would ask a sex offender about their sexual practices and why this would be important in any rehabilitive work. How could it not be? How they view/rate themselves, whether this be confidence, arrogance etc. would inform any practitioner about the person they’re working with. Then moving on to ask how any of their previous sexual partners viewed/rated them on these same practices could possibly give a different picture; a fuller picture, if you like. Say they told you they’d never felt confident enough to ask for certain things from a partner? How they dealt with that? Say they’ve never had a sexual partner before? How do they dealt with that too? I dunno. As they’re sex offenders then obviously boasting about certain practices which were part of the offence would DEFINITELY give a therapist an focus. Isn’t it all about getting to the crux of someone’s personality, about what makes them tick? Even the way someone tells you something gives you lot of information about them, their confidence levels etc. If a person refuses to answer (which one would have to put to them as a choice) this tells you a lot about someone too. Very often gaps in stories and what a person omits can sometimes be more telling than what a person chooses to divulge. Isn’t asking about THEIR sexual practices just a form of questioning which could lead one into circular questioning? Questioning which could lead to a sex offender putting himself into the victims shoes? From questions he/she can answer relatively easily, to ones he /she has to give a little more thought too. I think so. That’s just my take, anyway.

Also, I’m definitely with you on a patient needing to experience a level of comfort before any hard questions are asked – especially about something such as one’s appearance. Sensitivity in any human interaction is imperative, and I’m also of the opinion that if something is important it will come out soon enough.

The trouble with the professor is that it does appears that he wanted to satisfy his own curiosity. I’m no expert, but it doesn’t take a great leap to assume that a person with facial abnormalities is acutely aware that any person they engage with is conscious of their difference. Facial abnormalities are not something one can hide from. And, pardon the pun, but it’s also not, like many problems, physical or otherwise, something that can be masked. So, in a situation such as this, I assume that your professor sees this as almost an icebreaker. A tension relieving question. I can also see that the professor also probably thought “It’s not about how long one waits or how sensitively one addresses an issue, but more about how long does one leave it before both my client and I are charged and flattened by the metaphorical elephant in the room?” In his opinion the facial abnormality is probably going to be something between them. Something he possibly feels will hinder open and honest communication. In his rush to facilitate transparency he’s made the mistake of only looking at what the patient brings to the equation/interaction and not what the therapist brings too (i.e. age, gender, power, prejudice, whatever…). Getting bogged down in the minutia stops one from looking at the bigger picture. In some ways he was possibly trying to avoid a patient ever having to think “Oh yeah, here it is, I wondered when this was gonna come up?” or maybe even “Why didn’t she ask it sooner and get it over with?”or “I wish people would just ask what is so clearly on their mind…” and in some ways what he was doing there is admirable. Anaaad I can also see that he possibly thinks that addressing this early on gives the message to a patient that nothing is too difficult for YOU (the shrink) to address, and that this would also give a patient more confidence in your profession as a result, which is obviously what he’s all about promoting.

The trouble was, it backfired.

Not only did Shelly ask something in a ham-fisted way, but she asked AFTER consulting with the group/professor. This was a major faux pas to say the least. It probably seemed to the patient that the whole group was hung up on his face (not only Shelly), that THE WHOLE GROUP couldn’t see past this issue. Oh my, poor guy. That was where the real damage was done. As Shelly was unsure she should have kept schtum until she felt 100% confident about what she was about to do, that’s how one takes one’s responsibility to a patient seriously. I can see how she would have felt a pressure to perform though, her motivation was to help, after all. I’m sure a patient would feel much more confident in a shrink who said “let me think about this and get back to you, someone who takes a considered approach than in a ham-fisted way as illustrated here. This not only resulted in the patient being made to feel self-conscious but the therapist was made to feel uncomfortable too. This is what made things go from bad to worse. Obviously she’s gotta learn, but this should NEVER happen at a patient’s expense. Never.

I agree, it is likely that the patient didn’t come back because of WHAT she asked, but also HOW she asked it would surely have influenced things too, and I don’t mean by being insensitive. I mean by being under-confident. An therin lies the rub: confidence instils confidence and what happened here was quite the reverse.

The problem for me isn’t students being taught to ask the ‘hard question” either, it’s much more about this being the wrong situation in which to do it. It was a poor example. A poor way for you all to learn.

It sounds to me like your professor’s agenda that day was to teach/introduce “the hard question” rather than allowing the process to be much more organic. Everything just seemed forced. In my opinion, if what was generated during the session didn’t fit his teaching brief then he needs to wait for the right opportunity to present. Alas, I’m left with the feeling that he lost sight of one goal in favour of another. His duty of care in the situation you describe shoulda been to prioritise the needs of his patient over those of his students, and, in failing with the first, ultimately he failed everyone…

I decided to browse the healtcare website today and I read several articles . The featured article on depression lead me to your website. I am quite impressed. I am particularly interested in the “Bad Therapist” article. I was diagnosed with depression many years ago. As a young woman, I was trying to deal with my psyho-social transitions, college and depression. I was unfortunatly assigned an unethical therapist and I have since become very reluctant to speak with MH care professionals. At this time in my life I am experiencing some emotional upheavals, but I manage to bounce back. I realize that I must remain optimistic at all cost. My initial experience with the MH care prof. has shaken my ability to trust. This creates a definite problem when I really need to speak with a doctor. Can you give me your professional opinion?

@Nanette: please take a look at th Disclaimer. With that in mind, we are not all like that. When my friends have a bad experience, I encourage them to find someone else and to specifically share what went wrong with the prior therapist. Use his/her reaction to gauge your own comfort level. This can help a lot.

Some therapists have this notion that concepts of civility and rudeness somehow magically are different in the consulting room. In fact, because of expectations, the therapist’s tactlessness can seem magnified. Therapists can be so indoctrinated in theory, they forget how to be human.

Having experienced therapy from the patient perspective I can certainly say that number of years experience doesn’t necessarily make a difference to how well therapists come across.

The day of saying “what would you know I’ve got X years experience” is long gone in all jobs (very 1970s in my opinion) – its about what you did with those years and not being as complacent as to think that you’ve “made it”. That example above is a tough one and some people have it, others don’t. Good therapists ask tough questions and in a proper manner, but the key factor is knowing when your opportunity is missed. I think in this example Shelley needed to know how to ask the question about the lip in the initial assessment, there and then, rather than after the patient has seen her have a discussion with 5/6 others and would be self conscious about ANY questions. In fact once she’d had the discussion with others, wrapping up the session with no more serious questions would have been the right thing (and nobody seemed to point that out).

Having said all that, I can’t see how I could think that quickly and it is understandable as a student she was unsure about what to do and in a place where both options (saying something (and what?) vs saying nothing) were very, very difficult with someone assessing her. It therefore does seem a bit unfair to judge her on this one incident – maybe she learnt from it.

With therapists I’ve seen some have more glittering careers than others but good manners and/or judgement doesn’t necessarily come with experience, as it is difficult when you need patients to confront buried issues. The good ones did push me out of my comfort zone to confront issues rather than act like a supportive friend. The brakes need to be on – I’ve met some overexuberant morons (even one bully with 25+ years experience), so departure rates have to be examined more closely in this field as there is no other way of examining therapy. However, I did leave my first therapist way too early due to overexpectation so it’s not all about the therapist – maybe looking at long term rates would help?

I’m currently in school for counseling, and what absolutely blew me away was the reaction the professor gave to the student – all after, he was the one to make her inquire about the lip. As a student, you trust that your professor is leading you in the right direction, especially when it comes to dealing with real people and not fake scenarios. If this scenario happened with one of my professors, I’d take it up with the head of the department, and make sure something happened. Trusting your professor, following through with his advice, and then getting insulted when things don’t work out is terribly unfair. I would also have some serious doubts about remaining in the program with such a hostile professor.

In this post, I consider the student like the receptionist to the therapy. She takes down the standard info, asks why you’re here. You wouldn’t assume the receptionist at your doctor’s office was going to diagnose you in the waiting room. That’s essentially what I think the professor was trying to somehow facilitate. Having self-esteem issues is what seems to have happened here, but she isn’t responsible for asking ‘tough questions’. And even so, a therapist allows some breathing room between those tough questions.

I think bad therapy sticks with us more than other doctors. With medical doctors, if something doesn’t work out, the most you have to relay to your new one is your medical history, why you’re there today, and other standard things for most doctors. It’s different with psychologists, and I think that’s why people get such a strong impression of them (be they good or bad); you are trusting them with your thoughts/feelings/problems – sometimes things you don’t trust other people with. If things don’t work out with them, you have to start over. That means lugging all those loose ends, emotional baggage, and all of your hang-ups to someone completely new to unpack and/or cry over. Or you’re left to repack everything again, and move on.

I had a very bad experience in which I was feeling much better with a therapist who was kind, validating, and supporting. (I was going through a lot of major life changes and am high-fucntioning but was very depressed).

About a year into “therapy”, he began the abuse: swearing, interrupting, and name-calling. He was clearing projecting his own baggage onto me, and constantly felt the need to humiliate me and catch me off guard. I have since learned that not only are therapists trained to behave this way, but are not held accountable for it (my anger and consequent exit from therapy is blamed on transference)

It’s like there is an elephant in the room nobody wants to talk about, but fortunately I have had a few sessions with a therapist who has told me that many therapists are wounded when they enter the profession and dump their garbage on unsuspecting clients. I needed to know that I was the one that wasn’t crazy.

What I don’t understand is why the good therapists have such a hard time holding the bad therapists accountable. I’m in the healthcare profession, and we hold our colleagues accountable. Why is the therapy industry so defensive? Why do more not speak out? Why is it so hard to find accurate information? I was duped, and this is what hurts the most.

And if I were the client with the lip deformity, I would have seen a major red flag and would have left as well. The client did the right thing, he listened to his gut and honored himself by leaving, as did I.

Wow, the attitudes you display here provide a great illustration of the dehumanizing nature of therapy, and why it causes more harm than good. Not sure how you look in the mirror every day. Please stop hurting people, and get a real job.

I know you’re a CT guy and a gentle pragmatist, but as important as the 15 mantras you wisely repeat, you might remember the irreducible contribution of the father of modern psychology: we reveal who we are in what we say and in what we do not. Ultimately talk therapy, its ultimate efficacy and its ostensible lack of cost-effectiveness, relies on this most basic of insights.

I never thought therapy could be a problem. Each prof has good and bad. Then a friend recommended someone. Wow. The worst I could imagine. I am speaking about this 30 months later to tell everyone most therapists are OK. Some are good or great. Some are close to evil. I didn’t know this. I’m OK now but still think about it and it is still a secret I cannot share with everyone. However within support groups I have shared it . I have told 4 friends. I have told 3 therapists. I no longer care who kows but will still be careful bc some people don’t get it.